ORIGINAL ARTICLE ADDRESSING MATERNAL DEATHS Less than one percent of the 529,000 maternal deaths taking place annually occur in the developed world. The skewed distribution of Maternal Death and the maternal deaths can be illustrated by the following example: in Ma- lawi, pregnancy complications kills one of 50 women in reproduc- Millennium Development Goals tive age, whereas the same is the situation for one out of 50,000 women in Sweden [3]. Further, for every woman dying, at least 30 Vibeke Rasch, Associate Professor others will suffer complications which often end up being long-term and devastating. They include infertility and damage to the repro- ductive organs. The main causes of maternal deaths are: bleed- University of Copenhagen, Department of International Health. ing/hemorrhage (25%), infections (13%), unsafe abortion (13%), Correspondence: Department of International Health, Immunology and eclampsia (12%), and obstructed labour (8%). Other direct and in- Microbiology, University of Copenhagen, 1014 Copenhagen K, Denmark. direct causes account for the remaining 28% of maternal deaths [4]. E-mail: [email protected] There is not a simple and straight-forward intervention, which by it- self will bring maternal mortality significantly down; and it is com- Dan Med Bull 2007;54:167-9 monly agreed that the high maternal mortality can only be ad- dressed if the health system is strengthened. ABSTRACT Focusing on the health system, to address the poor health among Maternal health is one of the main global health challenges and reduction of rural populations and to improve maternal and child health, in- the maternal mortality ratio, from the present 0.6 mio. per year, by three- creasing emphasis was, in the 1970s and 1980s, placed on primary quarters by 2015 is the target for the fifth Millennium Development Goal health care for all through training of community health workers (MDG 5). However this goal is the one towards which the least progress has been made. There is not a simple and straight-forward intervention, which (CHWs) and traditional birth attendants (TBAs). However, CHWs by itself will bring maternal mortality significantly down; and it is com- and TBAs were often just trained briefly and left without a well monly agreed on that the high maternal mortality can only be addressed if functioning back up system. As a consequence, concern about the health system is strengthened. There is a common consensus about the whether the initiative at all had a positive impact on maternal deaths importance of skilled attendance at delivery to address the high, maternal mortality. This consensus is also reflected in the MDG 5, where the propor- was raised and governments were advised to stop training TBAs [4]. tion of births attended by skilled health personnel is considered a key indica- Since the 1990s, safe motherhood programmes have instead increas- tor. But even if countries invest massive efforts to increase skilled care, there ingly focused on the need for skilled attendance and emergency ob- will be a time lag. In addition, there is a need of major investment in human stetric care. resources to counter the present momentum of emigration of qualified per- sonnel from low income countries. To address the lack of skilled attendance, alternative strategies should therefore be developed and incorporated within SKILLED ATTENDANCE the existing health system. One plausible solution could be to involve lower In the early 20th century, industrialized countries halved their ma- level providers such as community health workers to provide health facility ternal mortality by providing professional midwifery care at child- based care under close supervision of authorized midwives. Upgrade of mid- birth and in the 1950s maternal mortality was further reduced by level staff to provide life-saving obstetric surgery may also be an important innovative strategy. Along with the strategy of aiming at increasing the improving access to hospitals [5]. A similar picture has been gener- number of health facility based deliveries and the empowerment of non ated in many low income countries where increased access to skilled physicians to provide obstetric surgery, some preventive functions of basic attendance with the back up of a well functioning health system has care targeting women who prefer to deliver outside the health facilities resulted in decreased maternal mortality [6-8]. Based on these ex- should be developed. Finally, political leadership, openness to discuss periences, long-term initiatives and efforts to provide skilled profes- women’s rights, including abortion, and involving the community i.e. MDG 3 is essential to attain MDG 5. sional care at birth are believed to be the way forward when aiming at addressing maternal mortality. The consensus about the importance of skilled attendance at de- MATERNAL DEATH AND THE COMMITMENT livery is also reflected in the MDGs, where the proportion of births FROM THE INTERNATIONAL COMMUNITY attended by skilled health personnel is considered a key indicator for Maternal health is one of the main global health challenges and re- the MDG 5 of improving maternal health and reducing maternal duction of the maternal mortality ratio by three-quarters by 2015 is mortality. It has been agreed that concerted efforts should aim at the target for the fifth Millennium Development Goal (MDG 5). globally increasing the number of births assisted by skilled attend- However this goal is the one towards which the least progress has ants to 80% in 2005 and 90% in 2015 [9]. However, issues sur- been made and complications during pregnancy and childbirth re- rounding maternal mortality have proven to be more complex than main a leading cause of death and disability among women of re- first realised, and the 2005 goal of 80% skilled attendance was fare productive age in developing countries [1]. The international com- from reached: only 50% of the births were assisted by skilled attend- munity has during the past two decades repeatedly dedicated itself ance in 2005 [4]. In assuring increased access to skilled attendance, to reduce the number of maternal deaths. In 1987, the Safe Mother- it has to be acknowledged that even if countries invest massive ef- hood Initiative, a coalition formed by the WHO, UNICEF, the forts to increase skilled care there will be a time lag. It has been esti- World Bank and the United Nations Population Fund was launched mated that additional 334,000 midwives need to be trained to assure at a conference in Nairobi. It committed itself to cut the number of all pregnant women access to skilled attendance [4]. Training this maternal deaths by half by year 2000. Some years later, in 1994 at the number of midwives will require new midwifery schools and teach- International Conference on Population and Development (ICPD), ers. In the meantime it will in particular be the poor women in rural this goal was reiterated and another target of a further 50% reduc- communities who will suffer from difficult access to safe delivery tion by 2015 was added. In 1995, the Fourth World Conference on care. In addition, retention of workers, especially in the poorest Women in Beijing gave substantial attention to maternal mortality countries, is a global concern, and there is a need of major invest- and confirmed the commitments made at the ICPD. Now, almost 20 ment in human resources to counter the present momentum of em- years after the first initiative, these aims have not been realised and igration of qualified personnel [10, 11]. the world is still faced with unacceptable high numbers of maternal TBAs are not considered skilled attendance, and since 1990, inter- deaths. The figures speak for themselves: in 1995 an estimated national agencies and academics, without robust evidence, have per- 515,000 women died from complications of pregnancy and child- suaded governments to stop training TBAs. Furthermore, TBAs, birth, in 2000 the corresponding figure was 529,000 [2]. regardless of whether they have received training or not, are in-

DANISH MEDICAL BULLETIN VOL.54NO. 2/MAY 2007 167 creasingly being excluded from having a role in maternity care community based interventions which aimed at involving women’s programmes. Evidence from a meta-analysis of training of TBAs, groups and strengthening the health system increased uptake of an- which identified no effect of training TBAs on maternal mortality tenatal and skilled delivery care and led to a significant reduction in [12] has lent support to this decision. The failure to detect an effect both neonatal and maternal deaths [17]. Further, a meta-analytic re- in the meta-analyses might, however, reflect difficulties in showing a view of effectiveness of TBA training to improve access to skilled modest effect on a rare event, such as maternal mortality and the birth attendance found positive associations between TBA training exclusion of TBAs may end up being counterproductive, especially and TBA knowledge of the value and timing of ANC services, TBA in the present context, where there is severe lack of human behaviour in offering advice or assistance to obtain ANC, and com- resources. Instead of excluding TBAs from providing maternity care, pliance and use of ANC services by women cared for by TBAs or liv- they may be considered as resource persons, who could be involved ing in areas served by TBAs [12]. in maternity care programmes, provided they are working under In spite of strong advocacy for facility based deliveries, some close supervision from trained nurses/midwives. Hence, alternative women will choose to deliver at home either with a skilled attend- strategies where TBAs knowledge and skills are acknowledged ant, an CHW or an TBA. For mothers who deliver at home, facility and incorporated within the existing health system may prove bene- based obstetric care alone is not likely to be a credible strategy for ficial. A recent study modelled six possible scenarios of maternity reducing maternal death. Therefore, along with the strategy of aim- care to test, whether birth attendants trained for a shorter time (six ing at increasing the number of health facility based deliveries, some months) versus those trained for longer (midwives) would achieve preventive functions of basic care targeting women who prefer to higher coverage [13]. Facility-based births with skilled midwives deliver outside the health facilities should be developed. Such strat- and assistants working under their supervision effectively in- egies have been evaluated and found to be associated with low ma- creased the number and proportion of women with professionally ternal mortality ratio in e.g the Netherlands and Malaysia [18]. assisted births. These findings support the idea of a health care Since the majority of all maternal deaths are caused by hemorrhage, model, where trained TBAs work under close supervision of author- one compelling strategy to reduce maternal mortality could be pro- ized midwives. vision of oxytocin by CHW or TBAs [19]. If such an approach is uti- lized for treatment of postpartum haemorrhage it might prevent EMERGENCY OBSTETRIC CARE many of the 140,000 annual maternal deaths from haemorrhage In addition to facility based skilled attendance, a well functioning [20]. Evidence from Tanzania where TBAs were trained to recognize health system with provision of equipment, drugs and other post partum hemorrhage and to give misoprostol, supports such a supplies is needed for the effective and timely management of deliv- course [21]. Likewise, acknowledging that infections are the second- ery complications, which may lead to maternal deaths. Recently, most important cause of death, the lives of many mothers may be much emphasis has been on making emergency obstetric care avail- saved, if antibiotics were made more easily accessible for CHWs and able to all women, who need it. It does not imply that all births TBAs [20]. should take place in well-equipped health facilities, but only that if a pregnant woman develops complications, she should be able to ac- UNSAFE ABORTION cess essential obstetric care. To ensure improved access to emergency It has been argued that the MDGs are too conservative, since they obstetric care, a well functioning referral system is mandatory. This are not addressing one of the major contributors to the high mater- means overcoming delays in recognition of complications and in nal mortality, namely unsafe abortion. Every year 68,000 women die gaining timely access to appropriate emergency obstetric care facil- as a consequence of complications from unsafe abortions, making it ities [14]. Additionally, for those women who develop obstetric one of the most significant contributors to the 529,000 annual ma- complications, a health worker (or team of health workers) who are ternal deaths. The target of reducing the maternal mortality ratio by trained, authorized, and supported to deliver the emergency care re- three-quarters by 2015 is not likely to be achieved if the problem of quired has to be present. Caesarean section is an intervention, which unsafe abortion is not addressed too. In addition, treatment of abor- can be life saving for both the mother and the child. In many coun- tion complications represents a significant burden to health care tries it is only physicians who are authorized to perform caesarean systems in countries with restrictive abortion laws; in some hospitals section. However, in rural areas there is often a shortcome of trained women admitted with incomplete abortion account for 50% of all physicians. To provide comprehensive emergency obstetric care in gynaecological and obstetrical patients; and it has been shown that such settings, alternative solutions should be sought, such as up- the majority of these women have in fact had an unsafe abortion grading midlevel staff to provide life saving obstetric surgery. [22, 23]. Debate has been ongoing about the negligence of unsafe Evidence from Mozambique, where no difference in post-operative abortion in the millennium development framework, especially in complications and the duration of post-operative hospital stay was the context of the ICPD. At the ICPD meeting it was, after signifi- found when comparing 958 caesarean deliveries performed by med- cant debate and discussion, decided to give priority to unsafe abor- ical assistants trained for surgery with 1133 performed by specialists tion and thereby reducing the negative impact of unsafe abortion on in obstetrics and gynecology, support such an approach [15]. women’s health. It was further acknowledged that achieving the Similar successful experiences have been achieved in Tanzania and ICPD goal of a 50% reduction in maternal mortality by the year Malawi. 2000 would not be accomplished without a serious, long-term com- mitment to addressing the consequences of unsafe abortion. The COMMUNITY INVOLVEMENT ICPD commitment to address the problem of unsafe abortion is re- As indicated above, the MDG 5 of reducing maternal mortality by flected in Paragraph 8.25 in the ICPD Programme of Action, which three quarters are unlikely to be achieved. One of the reasons for this acknowledges that improving abortion-related care is an essential may be that current safer motherhood programmes, which mainly strategy for improving women’s health. On this background and focus on the importance of deliveries taking place in health facilities based on years of advocacy by NGOs on the need to integrate sexual by skilled attendance, do not reach the poorest households. As a re- and reproductive health objectives into the MDGs, it was in 2005 sult of the health facility based focus, community based interven- suggested that the risks women face from unplanned births and un- tions have been neglected and undervalued [16]. However both pol- safe abortion should be incorporated into the monitoring of the icies for skilled care and community care are crucial for an effective MDG framework [24]. In October 2006, the United Nations’ Gen- health system. This is illustrated in the WHO’s model of health sys- eral Assembly gave its endorsement to include universal access to re- tems, which includes the community as a key component. Strong productive health by 2015 as one of the international community’s community services promote demand for skilled care. In Nepal, Millennium Development targets [25].

168 DANISH MEDICAL BULLETIN VOL.54NO.2/MAY 2007 CONCLUSION Up till year 2007, reducing maternal mortality has been the least successful among the MDGs. With only eight years left, it is more than doubtful, that the goal will be reached by year 2015. However, research has shown the way to some essential approaches, namely reconsidering inclusion of TBAs, upgrading mid-level health staff, supervising and encouraging staff, among others by trusting its cap- ability to use oxytocin and antibiotics, and even do obstetric sur- gery, and at the same time attempting to reverse brain-drain of qual- ified health staff. Political leadership and willingness to discuss women’s rights, family planning and safe abortion openly, i.e. MDG 3 (“promote gender equality and empower women”) and involving the community in general are as essential for MDG 5 (“improve ma- ternal mortality”) as for achieving MDG 6 (combat HIV/AIDS, Ma- laria and other diseases).

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